Category: Without Borders

The published literature in global neurology over the past 1-2 months sure seems to be one sad tale of stroke woe after another for low income countries and populations. In Neurology, Kaddumukasa at al. in “Influence of sodium consumption and associated knowledge on post-stroke hypertension in Uganda” delineated gaps in care and patient knowledge that offer some direction in terms of the health education needs for post-stroke patients. In our associated editorial, Dr. Luciano Sposato and I share our perspectives on what this may mean for secondary stroke prevention efforts in Africa. In the Lancet, Healey and colleagues’ prospective cohort study of people presenting to Emergency Departments with atrial fibrillation or flutter from 47 countries provided further evidence that people with stroke in low and lower-middle income countries (LMICs) have worse outcomes. At 1-year follow-up, people from South America and Africa had 20% mortality compared to only 10% in more developed settings with untreated hypertension likely accounting for a substantial proportion of the excess mortality. Hypertension is quite the ubiquitous culprit in Africa. The Nigerian Journal of Clinical Practice published an epidemiological survey of hypertension in the Anambra state of Nigeria. In this church-based cross sectional study of adults from 17-79 years of age, 23% had hypertension with only 10% having a prior diagnosis. Hypertension was associated with several potentially modifiable risk factors including smoking, low levels of physical activity, alcohol consumption, and a poor diet.

Check out this interesting review article on zoonotic meningitides by van Samkar and colleagues from the Netherlands. They point out that zoonoses of this nature are relatively uncommon—but in reality in resource limited tropical settings, we don’t generally have the capacity to definitively diagnose zoonotic infections clinically and there are virtually no epidemiologic insights on this at all from low income settings. Key risk factors identified in the review include residence in sub-tropical regions, close exposure to animals, consumption of poorly prepared or unpasteurized animal products and an immunocompromised state. These are all very common exposures in sub-Saharan Africa given the ongoing HIV epidemic and rural living conditions that place humans in very close proximity to their domestic animals and livestock. Animals in sub-Saharan Africa often have sub-optimal health as well further increasing the risk of illness transmission to humans. Collaborations between clinical researchers and veterinary medicine specialists are needed to explore this further1

The online Urban Dictionary defines “get ‘er done” as a redneck phrase meaning to go ahead and complete a task and Yahoo answers says it is a phrase used in the military meaning don’t waste time, no matter how difficult the task, just do it and get it done. After reading the Global Perspectives section of this week’s Neurology, I think there can be no better adjective to describe the RIO GBS-ZIKV Research Network than to call them a get ‘er done team. This multidisciplinary group of self-funded clinicians and researchers in Rio using low cost technologies, like WhatsApp for group communications, have organized themselves into a lean, mean Zika fighting machine. While authoritative global health organizations are still trying to agree upon basic definitions (what IS microcephaly?), team RIO has developed standardized data collection instruments, protocolized treatment strategies and streamlined referral and triage procedures all while also collecting foundational data on the neurologic manifestations of Zika Virus in Brazil. Don’t miss what promises to be the first of many interesting reports from this inspiring group.

Although the World Health Organization (WHO) announced there would be additional meetings to review the public health risks associated with the 2016 Olympics scheduled to commence on August 5th in Rio, no new updates have been released to date (30 June). WHO’s recommendations in May indicated that holding the Olympics in Brazil would not appreciably alter the risk of spread of Zika. Pregnant women were advised not to travel to any Zika-affected regions and other Olympic attendees should avoid mosquito exposure, unprotected sex and travel to poor regions of Brazil more affected by Zika. The Rio Olympic Committee leadership have openly stated they will follow any WHO recommendations including, presumably, canceling the event. WHO maintains that it isn’t within their mandate to make decisions regarding the Olympics. If you are mind-numbingly frustrated with WHO’s handling of this looming issue, you might find a kindred spirit in Richard Horton’s June offline commentary—WHO’s Phoney War..1

As the program promised, the AAN Annual Meeting in Vancouver was teeming with internationally oriented activities and programs. In addition to the Global Heath Session (which admittedly, you needed a compass and breadcrumbs to find), there were presentations on work outside of the US interspersed at many of the other Sessions, HeadTalks addressing issues in Global Neurology, an INS on Practical Approaches to Narrowing the Epilepsy Treatment Gap and an excellent presentation by Rufus O. Akinyemi, MD of Ibadan, Nigeria with his acceptance of the Bruce S. Schoenberg International Award in Neuroepidemiology. Drs. Omar Siddiqi (from Harvard’s BIDMC and the University of Zambia) and Kiran Thakur (Columbia University) took up the leadership gauntlet within the AAN’s Global Health Section. Check out Synapse for more details on the program they are envisioning and planning for the coming 2 years.

The 68th Annual Meeting for the American Academy of Neurology in Vancouver will start next week. This year features a significant change in the structure of the meeting—access to MOST of the sessions is now entirely included in the basic registration fee. For the neurologist practicing in a resource limited setting who may be working without ready access to a large cadre of sub-specialized neurology colleagues, this means having the option of picking and choosing within the sub-specialty programs for those specific sessions most relevant to one’s own setting and situation. This year’s program also features three sessions on Teleneurology, which is a growing opportunity for expanding the reach of neurologic expertise while also providing ongoing support to colleagues working in situations with few other neurologists.Topical coverage of Neuroinfectious Diseases is also especially robust this year. Saturday, Global Health is going strong with, “Navigating your career: International Resident and Fellow Roundtable” , Global Health Session and excellent international coverage in Poster Session 1 (Global NCDs, Global capacity building, neuro-ID and neuro-HIV topics). Tuesday is the Global Health section meeting—an important opportunity to get involved in the sections leadership or simply offer your perspectives on growth priorities for the section. Wednesday from 3:30-5:30pm is “Neurocysticercosis and Globalization” and Thursday 1:00pm-5:30pm “Practical Approaches to Narrowing the Epilepsy Treatment Gap”. A new feature this year will be Experiential Learning with HEADTalks—15 minute presentations modelled from the now famous TED talk forum with select speakers presenting well-developed perspectives on timely topics. Neurology:Without Borders is clear evidence of Neurology’s (a.k.a. the green journal’s) growing interest in international research and engagement. On Monday at 5pm you have the opportunity to ask Robert Gross, Editor-in-Chief of Neurology anything global or otherwise. Hope to see you in Vancouver!

Epilepsy care in African countries continues to rely largely upon older antiepileptic agents, so new findings in Acta Tropica by Motshoge and colleagues are of interest to physicians working in the region1. They evaluated the prevalence of CYP2C8*2, a slow drug metabolism allele, in San and Bantu populations in Botswana and found 17.5% amongst the San compared to 8.5% in the Bantu. The authors credit the differing evolutionary pressures on hunter-gatherers (the San). CYP2C8*2 is particularly important in the metabolism of carbamazepine and is virtually absent outside of African populations.2 Prior studies have indicated the San are also more likely to be slow acetylators3 and have lower CYP2D6 activity as well.4

Good news. The 2015 World Malaria report recently released by the World Health Organization estimates that the number of malaria deaths fell by ~42% between 2000 and 2015. Most of the decreased mortality occurred in the WHO African region where most deaths occur and where severe disease occurs largely in children. Although the Malaria Report doesn’t capture neurological disabilities that result from malaria infections, multiple African studies have shown that 12-30% of pediatric cerebral malaria survivors experience neurologic sequelae including epilepsy, neurodevelopmental disabilities, cognitive impairment and behavioral disorders [1-9]. Assuming severe malaria infections have also decreased with mortality, many “brains” are also being saved by global reductions in malaria infections.

Just as Neurology: Without Borders launched last week, news coverage about the Zika virus epidemic in Latin America with Brazil at ground zero began to reach even the popular press. 1-4 Photos of devastated parents and microcephalic, dysmorphic infants have captured the public’s attention. Recent articles in the New England Journal of Medicine 5 and Lancet 6-8 among others have outlined some of what is known about the epidemiology of this arbovirus and how we believe it made its way from Africa (identified in 1947), to Southeast Asia (mid-twentieth century), to Micronesia (2007), to French Polynesia (2014) and most recently to Latin America in 2015.9